journal of prosthodontic research 60 (2016) 258264

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Journal of Prosthodontic Research

journal homepage: www.elsevier.com/locate/jpor

Original article

Changes in oral health-related quality of life during

implant treatment in partially edentulous patients:
A prospective study

Tadashi Yoshida DDSa, Chihiro Masaki DDS, PhDa,*,

Hideki Komai DDS, PhDa, Saori Misumi DDS, PhDa,
Taro Mukaibo DDS, PhDa, Yusuke Kondo DDS, PhDa,
Tetsuji Nakamoto DDS, PhDb, Ryuji Hosokawa DDS, PhDa
a
Department of Oral Reconstruction and Rehabilitation, Kyushu Dental University, Japan
b
Department of Prosthodontics, Graduate School of Oral & Maxillofacial Biology, School of Dentistry,
Matsumoto Dental University, Japan

article info abstract

Article history: Purpose: The aim of this prospective study was to evaluate the changes in oral health-related
Received 8 September 2015 quality of life (OHRQoL) during implant treatment for partially edentulous patients, and to
Received in revised form evaluate the influence of the type of partially edentulous arch.
13 January 2016 Methods: Twenty patients with a small number of lost teeth (fewer than 4 teeth) who
Accepted 27 January 2016 underwent implant treatment were selected. Chronological QOL change during implant
Available online 8 March 2016 treatment was measured. The subjects completed the shortened Japanese version of the
Oral Health Impact Profile (OHIP-J14) before the surgery (T0), 1 week after the surgery (T1), 1
Keywords: week after interim prosthesis placement (T2), and 1 week after definitive prosthesis
Implant placement (T3). Complete data of the twenty subjects were analyzed with the Wilcoxon
OHRQoL signed-rank test.
OHIP Results: The total OHIP-J14 score was significantly reduced only at T3 (P < 0.05). Physical
pain and Physical disability scores significantly decreased at T3, and Psychological
discomfort scores also significantly dropped at T2. However, Functional limitation scores
significantly increased at T1. Psychological disability, Social disability, and Handicap
scores remained the same. On the other hand, in the comparison depending on the type of
partially edentulous arch, the total OHIP-J14 score significantly decreased at T3 in the
unilateral free-end edentulous space, whereas no significant difference was observed in
the bounded edentulous space.
Conclusion: Although there is a temporary functional limitation after implant placement in
overall OHRQoL improvement was observed after the definitive prosthesis placement. More-
over, implant treatment was more effective in the unilateral free-end edentulous space.
# 2016 Japan Prosthodontic Society. Published by Elsevier Ltd. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

* Corresponding author at: Department of Oral Reconstruction and Rehabilitation, Kyushu Dental University, 2-6-1 Manazuru, Kokurakita,
Kitakyushu, Fukuoka 803 8580, Japan. Tel.: +81 93 582 1131; fax: +81 93 592 3230.
E-mail address: masaki@kyu-dent.ac.jp (C. Masaki).
http://dx.doi.org/10.1016/j.jpor.2016.01.010
1883-1958/# 2016 Japan Prosthodontic Society. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
 journal of prosthodontic research 60 (2016) 258264
1. Introduction
The goals of prosthodontic treatment for tooth loss are recovery
from functional and esthetic problems and improvement of
patients QOL. Implant-supported fixed dental prostheses have
been widely used as one of the prosthodontic treatments for
missing teeth, and a high success rate has been reported [1,2].
However, since there are many implant treatment methods,
oral health-related quality of life (OHRQoL) in implant treat-
ment has not been fully understood. In addition, most of the
previous reports based on clinical assessment [36], evaluation
of health workers (objective clinical evaluation) and evaluation
of patients (subjective evaluation) do not correspond to each
other [79]. Therefore, an outcome index from the point of view
of patients is important.
Patient-reported outcome measures (PROMs) have been
reported to be indispensable to evaluate the benefits of dental
implant therapy in different clinical situations as part of dental
implant research [10,11]. The methods of PROMs include the
General Oral Health Assessment Index (GOHAI) [12], Dental
Implant Profile (DIP) [13], Oral Health Impact Profile (OHIP) [14],
and Subjective Oral Health Status Indicator (SOHSI) [15]. Among
these, OHIP is a self-reported questionnaire on OHRQoL
consisting of 49 questions under seven subscales [14]. It has
been translated into different languages and used worldwide,
including in China [16], Germany [17], Spain [18], Brazil [19] and
Japan. Shortened versions have also been introduced [2022] to
reduce the response time, such as OHIP-14 [23,24]. The Japanese
version of the OHIP is also a valid questionnaire to measure the
oral health-related QOL, and it has been reported to facilitate
evaluation of the effectiveness of prosthodontic treatment [25].
A number of studies on patient-reported outcomes of
implant treatment have been conducted regarding implant-
supported overdentures and implant-supported fixed pros-
theses for a single or small number of missing teeth [2630].
However, few studies have demonstrated a change in detailed
patient-reported outcomes during implant treatment. Fur-
thermore, when performing conventional removable denture
therapy for a partially edentulous arch lacking 2 or 3 teeth, the
therapeutic effects and patient satisfaction level vary between
Kennedy classification types II (a unilateral edentulous area
located posterior to the remaining natural teeth) and III (a
unilateral edentulous area with natural teeth both anterior
and posterior to the area). Similarly, when performing implant
therapy, the patient satisfaction level is likely to vary
depending on the type of partially edentulous arch. However,
to the present, there have been no reports on this issue. The
aim of this prospective study was thus to evaluate the change
in OHRQoL in patients with a small number of lost teeth during
implant treatment at each treatment step, and to evaluate the
influence of the type of partially edentulous arch, such as
bounded and unilateral free-end edentulous space.
2. Materials and method
2.1. Subjects
The subjects (n = 20) were partially edentulous patients (the
number of missing teeth was three or less) who underwent
259
implant surgery at Kyushu Dental University Hospital be-
tween March 2010 and September 2011. They were well
informed about the study protocol and provided their written
consent for participation. This research was approved by the
Ethics Committee of Kyushu Dental University (approval
number 11-59) and followed the guidelines of the amended
Declaration of Helsinki. We excluded patients with certain
criteria (severe diabetes, previous chemotherapy, previous
irradiation of the head and neck region, progressive periodon-
titis, immunosuppression, human immunodeficiency virus
infection), as well as those who had poor oral hygiene or were
pregnant. Patients who needed bone grafting were also
excluded.
2.2. Surgical and prosthetic procedure
In six subjects, the surgery was performed under intravenous
sedation in addition to local anesthesia. Only local anesthesia
was used in 14 subjects.
One to three rough titanium implants (NobelSpeedy
Groovy, Nobel External Mark III, Nobel Replace Tapered
Groovy; diameter, 3.55.0 mm; length, 8.518 mm; Nobel
Biocare, Tokyo, Japan or Straumann TE implant; diameter,
3.34.8 mm; length, 8.010 mm; Straumann, Tokyo, Japan)
were placed in each jaw using the conventional protocol. The
initial fixation torque was more than 30 Ncm. The acrylic
interim prosthesis was fixed at least 2 months after the
surgery, when the Periotest value was less than zero [31]. The
definitive prosthesis was placed after another month or more,
when the marginal bone and soft tissue had stabilized.
2.3. Evaluation of OHRQoL
The shortened Japanese version of the OHIP (OHIP-J14) was
used [32,33] to assess OHRQoL. The subjects answered 14
questions under seven subscales (two items each) using five
choices before the surgery (T0), 1 week after the surgery (T1), 1
week after interim prosthesis placement (T2), and 1 week after
definitive prosthesis placement (T3). Scoring was as follows:
very often = 4; fairly often = 3; occasionally = 2; hardly ever = 1;
and never = 0. The total OHIP-J14 score (range 056) and
subscale scores (range 08) were then calculated, with a higher
score suggesting lower OHRQoL.
2.4. Statistical analysis
The Wilcoxon signed-rank test was used for comparisons of T0
with T1, T2, and T3. Then, Bonferroni correction was applied.
P < 0.05 was considered significant.
3. Results
3.1. General findings
The mean patient age was 51.9 years (range 3477 years). Ten
women and 10 men received dental implants (8 and 25 in the
maxilla and mandible, respectively): there were 6 bonded
edentulous space cases and 14 unilateral free-end edentulous
space cases (Fig. 1).
260 journal of prosthodontic research 60 (2016) 258264

Fig. 1 The two types of partially edentulous arch. (A) The unilateral free-end edentulous space. (B) The bounded edentulous
space.

OHIP-J14 total score Functional limitation Physical pain Psychological discomfort

*P=0.017 8 8 8 *P=0.015
*P=0.026
50 7 7 7
*P=0.043 *P=0.001
6 6 6
40
5 5 5
30 4 4 4

3 3 3
20
2 2 2
10
1 1 1

0 0 0 0
T0 T1 T2 T3
Before After Provisional Final T0 T1 T2 T3 T0 T1 T2 T3 T0 T1 T2 T3
Implant Implant Restoration Restoration
Surgery Surgery

Physical disability Psychological disability Social disability Handicap

8 8 8 8
*P=0.023
7 7 7 7

6 6 6 6

5 5 5 5

4 4 4 4

3 3 3 3

2 2 2 2

1 1 1 1

0 0 0 0
T0 T1 T2 T3 T0 T1 T2 T3 T0 T1 T2 T3 T0 T1 T2 T3

Fig. 2 Line graphs showing changes in median total and subscale scores of the shortened Japanese version of the Oral
Health Impact Profile (OHIP-J14) at the different assessment points. The total score ranges from 0 to 56 and every subscale
score ranges from 0 to 8. T0, before the surgery; T1, 1 week after the surgery; T2, 1 week after interim prosthesis placement;
and T3, 1 week after definitive prosthesis placement.

3.2. Total and subscale OHIP-J14 scores
The total OHIP-J14 score was significantly reduced at T3, but not
at T1 or T2 (P < 0.05). Physical pain and Physical disability
scores significantly decreased at T3, and Psychological
discomfort scores also significantly dropped at T2. However,
Functional limitation scores significantly increased at T1.
Psychological disability, Social disability, and Handicap
scores remained the same throughout the treatment (Fig. 2,
Table 1). On the other hand, in the comparison depending on the
type of partially edentulous arch, the total OHIP-J14 score
significantly decreased at T3 in the unilateral free-end edentu-
lous space, whereas there was no significant difference in the
bounded edentulous space (Fig. 3, Table 2).
3.3. Item scores
The results of the individual items are summarized in Table 1.
Pronunciation (item 1) scores significantly increased only at
T1. On the other hand, self-consciousness (item 5) scores
 journal of prosthodontic research 60 (2016) 258264 261

Table 1 Statistical findings of the individual items of the OHIP-J14.

Item Median (range) P

T0 T1 T2 T3 T0 vs. T1 T0 vs. T2 T0 vs. T3

*
Functional limitation 1 0 1 1 0 0.043 0.623 2.206
(02) (03) (02) (02)
2 1 1 1 1 0.623 3.000 3.000
(02) (02) (01) (01)
Physical pain 3 1 1 1 0 1.441 1.324 0.054
(03) (02) (01) (01)
4 1 1 0 0 2.442 1.981 0.223
(02) (01) (01) (01)
Psychological discomfort 5 1 1 1 1 0.280 0.015* 0.023*
(03) (04) (02) (02)
6 0 1 0 0 1.389 0.083 0.054
(01) (02) (01) (01)
Physical disability 7 1 1 1 1 1.661 0.329 0.035*
(02) (02) (02) (02)
8 1 1 1 0 2.259 0.484 0.189
(03) (03) (03) (01)
Psychological disability 9 1 1 1 1 1.781 0.858 0.461
(03) (04) (02) (02)
10 1 1 1 1 2.206 0.623 0.533
(03) (02) (01) (01)
Social disability 11 1 1 1 1 0.675 0.999 0.370
(02) (03) (02) (01)
12 1 1 1 1 1.389 0.623 0.427
(04) (04) (02) (01)
Handicap 13 1 1 1 0 3.000 1.726 0.641
(02) (02) (01) (01)
14 1 1 0 1 0.326 3.000 2.206
(03) (03) (02) (01)
OHIP-J14, shortened Japanese version of the Oral Health Impact Profile; T0, before the surgery; T1, 1 week after the surgery; T2, 1 week after
interim prosthesis placement; and T3, 1 week after definitive prosthesis placement.
*
P < 0.05 by the Wilcoxon singed-rank test with Bonferroni correction.

Fig. 3 Line graphs showing changes in median total and subscale scores of the OHIP-J14 at the different assessment points
between two types of partially edentulous arch. (A) The unilateral free-end edentulous space (B) The bounded edentulous
space.
262 journal of prosthodontic research 60 (2016) 258264

Table 2 Statistical findings of the comparison depending on the type of partially edentulous arch.
Median (range) P

T0 T1 T2 T3 T0 vs. T1 T0 vs. T2 T0 vs. T3

Functional limitation F 2 2 2 2 0.141 3.000 2.438
(03) (04) (03) (03)
B 0 2 2 1 0.432 0.604 1.268
(03) (03) (02) (02)
Physical pain F 2 2 2 2 0.854 2.397 0.107
(04) (05) (04) (02)
B 3 3 2 2 1.396 1.036 0.317
(06) (04) (02) (02)
Psychological discomfort F 2 2 2 2 0.710 0.035* 0.054
(04) (03) (03) (02)
B 2 2 2 1 0.855 0.326 0.326
(05) (05) (03) (02)
Physical disability F 2 2 2 1 3.000 0.279 0.054
(06) (05) (03) (02)
B 1 1 1 0 1.268 1.779 0.539
(04) (02) (02) (02)
Psychological disability F 2 2 1 1 0.788 0.329 0.623
(04) (04) (03) (02)
B 2 1 2 1 2.145 3.000 0.539
(02) (04) (03) (02)
Social disability F 2 2 1 1 1.341 0.206 0.273
(04) (03) (02) (02)
B 1 0 2 0 0.539 0.820 3.000
(02) (02) (02) (02)
Handicap F 2 2 2 1 0.189 1.501 1.452
(04) (05) (03) (03)
B 1 0 1 0 0.326 2.145 1.268
(02) (02) (02) (02)
OHIP-J14, shortened Japanese version of the Oral Health Impact Profile; T0, before implant surgery; T1, 1 week after placing the initial acrylic
interim prosthesis; T2, 1 week after placing the secondary acrylic interim prosthesis; and T3, 3 months after placement of the definitive
prosthesis with titanium framework. F, The unilateral free-end edentulous space; B The bounded edentulous space.
*
P < 0.05 by the Wilcoxon singed-rank test with Bonferroni correction.

significantly dropped at T2 and T3, dietary satisfaction (item
7) also significantly decreased at T3.
4. Discussion
Most previous studies on patient-oriented outcomes of
implant treatment focused on implant-supported overden-
tures [3436]. It has been reported that the implant over-
denture treatment in mandibular edentulous patients
improves patients satisfaction level, denture stability, and
retention [37]. We have reported that only a small improve-
ment of OHRQoL was observed after acrylic interim prosthesis
placement when immediate loading of the fixed dental
prosthesis was applied in edentulous patients, whereas a
definitive prosthesis with metal framework was the most
effective at restoring OHRQoL [30]. We investigated the
influence of implant treatment in patients with a small
number of lost teeth on OHRQoL. The results showed that
there was no improvement in OHRQoL after the placement of
implant and interim prosthesis, and the OHIP-J14 total score
decreased only after definitive prosthesis placement, suggest-
ing the improvement of OHRQoL. Physical pain, Physical
disability, and Psychological discomfort scores significant-
ly decreased at T3, suggesting that these 3 scores may
contribute to the improvement of QOL in implant treatment.
It has been reported that the most important factor affecting
QOL was Psychological discomfort [29]. Psychological dis-
comfort decrease was observed in T2, suggesting that a
temporary prosthesis increases a certain level of QOL in the
implant treatment of patients with a small number of lost teeth.
On the other hand, Functional limitation scores significantly
increased at T1, suggesting that implant placement transiently
affected postoperative pronunciation and the sense of taste.
Similarly, Eitner et al. suggested decreased OHRQoL in the
healing period of conventional implant procedures.
Interestingly, significant score differences were observed in
items 1, 5 and 7 (Table 1). The weights of these items in OHIP-
14 are 0.51, 0.45, and 0.52, respectively [38]. Two of these
questions have more than 50% weight, suggesting that any
differences would be more apparent.
In unilateral mandibular distal extension edentulous
patients, oral-condition-related QOL levels for dental implant
patients were higher than those of patients with a removable
partial denture or no restoration [39]. In addition, in patients
with bounded edentulous spaces, multidimensional QOL
levels of patients with an implant-supported fixed prosthesis
did not exceed those of patients with a resin-bonded fixed
prosthesis in a short follow-up period [40]. These reports
suggest that QOL may differ depending on the type of partially
edentulous arch. In the present study, subjects were divided
into bounded and unilateral free-end edentulous spaces for
 journal of prosthodontic research 60 (2016) 258264
evaluation. In unilateral free-end edentulous patients, the
total score of OHIP-J14 significantly decreased at T3, whereas
there was no change in the total score of OHIP-J14 before and
after the treatment in the bounded edentulous patients. These
results suggested that implant treatment may be more
effective in the unilateral free-end edentulous space. Howev-
er, because the average preoperative OHIP-J14 score was lower
in the bounded edentulous patients than in the free-end
edentulous patients, the possibility of the floor effect of the
bounded edentulous patients cannot be ruled out. The
difference in preoperative OHIP-J14 score between the two
groups may be due to the presence of the remaining occlusal
support for the molars and higher stability of the conventional
removable dentures in the bounded edentulous patients.
However, as the number of bounded edentulous patients was
limited in the present study, further studies involving an
increased number of subjects may be indispensable to
examine the effects of implant therapy on such patients.
Although patient satisfaction was evaluated using patient-
reported assessment items, such as pain, comfort, and the
attributes of the physical, social, and psychological impact of
the oral health status in the present study, there are other
important factors related to the QOL, represented by the
socioeconomic status and personality [41,42]. As these 2
factors were not evaluated in the study, it may be necessary to
perform multivariate analysis to examine relationships with
them in future studies.
Although we performed a prospective study, the number of
subjects was small. Further studies with a larger number of
subjects are required to elucidate the difference between
maxilla and mandible, and gender- and age-related variations.
5. Conclusions
Although there is a transient functional limitation after
implant placement in patients with a small number of lost
teeth, an overall improvement of OHRQoL was observed after
the placement of a definitive prosthesis compared with that
preoperatively. The mitigation of Physical pain and Psy-
chological discomfort, and improvement of Physical dis-
ability (e.g. difficulty eating) contributed to the improvement
of OHRQoL. Although it is inappropriate to simply compare the
2 groups, as there were significant differences between the
free-end situation and bounded edentulous space, the results
showed that implant treatment is effective to improve free-
end edentulous patients QOL.
Conflict of interest
The authors have no conflict of interest with respect to the
manuscript content or funding.
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